Provider Demographics
NPI:1598981466
Name:DALE, JACQUELINE BEATRICE (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BEATRICE
Last Name:DALE
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:BALLARD
Other - Last Name:DALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSCCCSLP
Mailing Address - Street 1:111 ROBIN HOOD DR
Mailing Address - Street 2:
Mailing Address - City:COXS CREEK
Mailing Address - State:KY
Mailing Address - Zip Code:40013-7629
Mailing Address - Country:US
Mailing Address - Phone:502-460-4282
Mailing Address - Fax:502-350-4282
Practice Address - Street 1:111 ROBIN HOOD DR
Practice Address - Street 2:
Practice Address - City:COXS CREEK
Practice Address - State:KY
Practice Address - Zip Code:40013-7629
Practice Address - Country:US
Practice Address - Phone:502-460-4282
Practice Address - Fax:502-350-4282
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-2540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist